Editor's blog: Ice-water training inquest

May 18, 2017, Toronto - A firefighter with experience in water-ice rescue testified Wednesday at an inquest examining training deaths that he avoids exercises in icy, swift water because it is too dangerous.

Further, said acting Capt. David Gillespie with the Peterborough Fire Department, the area at the foot of a low-head damn called the boil is known as a “drowning machine” and is unsafe for training. Gillespie recommended rescue techniques in such conditions be shore-based or technical rather than in-water.

Firefighting student Adam Brunt died after part of his Ice Commander suit got caught on a piece of rebar in the Saugeen River on Feb. 8, 2015. Brunt and other firefighting students from Durham College had been training with Herschel Rescue principle Terry Harrison – 12 students, one instructor – diving into the boil and learning how to ride the current. Herschel is one of several private, unregulated training providers in the province.

Gillespie said his department avoids sending rescuers into the boil of a low-head damn.

“When it comes to what your rescue options are, we . . . look at how would you use ropes strung across the river and could you run a life jacket or a ring, but the survivability of somebody in cold water in that drowning machine is negligible,” Gillespie said.

Harrison testified last week that he had taken the Durham College students into the Saugeen River in Hanover, Ont., near the low-head damn and had them dive into the boil to experience the current. Brunt was third in line as the students floated down the river, out sight of Harrison, who was at the rear.

The jury has heard there was no safety officer or spotters with the group and no emergency plan, that the students were inexperienced, and that while there are swift-water training programs and ice-water training programs, rarely do instructors have students train in swift water when there is also ice.

Harrison has said the St. Clair River, in which firefighter Gary Kendall died during training in 2010, is among the most dangerous bodies of water in the province – along with the Ottawa River – and said he was excited to experience its challenges when he worked with the Point Edward Fire & Rescue, a volunteer department, in 2009 and 2010.

“Should a training exercise ever present a high risk to the trainees?” David McCaskill, lawyer for the Ministry of Labour, asked Gillespie Wednesday.

“No,” Gillespie said.

“Would you agree with me that the degree of risk has to match the degree of training?

“Yes,” Gillespie said. “You don’t exceed that capability.”

Gillespie is an experienced kayaker – he was the safety co-ordinator for the Pan-Am Games swift-water site in Minden; he was a training officer; and he has been the lead instructor for the firefighting program at Fleming College in Cobourg, Ont., since 2002. Gillespie said he has worked with municipalities to rewrite their establishing and regulating bylaws.

Gillespie and Harrison worked together in the 1990s to develop a five-day course in flat water and swift water, and a three-day program for ice rescue (not swift-water ice rescue) for the Ontario Fire College. The college put its ice-water rescue training on hold in August 2015.

Coroner’s counsel Michael Blain questioned Gillespie about the differences between flat water rescue and swift-water rescue.

“There’s enough safety procedures in place that on flat water there’s a reasonable possibly of success,” Gillespie said. “We’ve had very good success in my department conducting rescues.”

Gillespie testified that swift-water rescue requires specialized training and equipment and that it is “quite reasonable based on current day practices to affect a rescue.” But in cold, or icy, swift water, the likelihood of a rescue diminishes.

“My experience is in cold, swift water . . . that’s a different beast. It’s not a common training location; the rescues that take place are very rare and in my experience we’ve not had success.”

One of the problems, Blain suggested, is that by the time a witness calls 911 and rescuers arrive and gear up, it’s not unusual for a patients to have succumbed to the conditions.

“So in terms of affecting a rescue it’s a very low margin?” Blain asked.

Gillespie agreed.

“We’ve also heard,” Blain said, “that local agencies should train where they might respond. What are your thoughts on that?”

Gillespie said only the Ottawa Fire Department’s specialized technical rescue team, which logs a minimum of 40 hours of progressive training, runs exercises in swift water conditions with ice. Other members of the department may attend rescues but operate from the shore only.

“I’ve talked to Thunder Bay, Sault. Ste. Marie . . . and our department, and that’s a no go,” Gillespie said. “What we do train for is situations in which we can affect a rescue.”

Jurors will be charged Friday to make recommendations and are expected to report back Tuesday. Coroner’s counsel introduced proposed recommendations on Wednesday, seeking input from Gillespie.

Essentially, Blain said, the fire college ice-rescue program should remain on hold until a committee of subject-matter experts deems that the standards and equipment are such that the risk to participants is minimized, and that if such training resumes, it be in designated locations, “not necessarily the fastest and worst water where the risk is high.”

“The agencies that I’m affiliated with practice many of these steps,” Gillespie said, “in designated areas where there is low risk.”

The fire college expects to re-introduce water rescue training this summer and an ice-water (flat water rather than swift water) program in early 2018, with a standard curriculum.

“And everybody doing this training will abide by that curriculum,” Blain said, including private training providers. “Does that make sense?”

“Yes,” Gillespie said, agreeing that the fire college or the Office of the Fire Marshal and Emergency Management (OFMEM) should work with the Ministry of Labour Section 21 committee to ensure the curriculum meets health and safety concerns.

“And once we have the curriculum for each course, all providers have to abide by that course,” Blain said. “That might mean that private companies have at least some regulation, because they have to abide by the curriculum.”

Further, Blain said, the OFMEM should contact all municipalities that have fire services, and the fire chiefs, to review their establishing and regulating bylaws to ensure the legislation properly addresses the level of service and the training necessary to provide it.

“I would hope,” Gillespie said, “that you help municipalities that have water bodies in their communities to identify what areas are no go . . . I think identifying that no-go is an option is a recommendation [to be] considered.”

The jury has heard testimony from firefighters and a fire chief who have there is a public expectation for firefighters to attempt rescues if they are called to even the most dangerous situations. If municipalities determine that rescues in swift, icy water are too dangerous for volunteer firefighters who have fewer training opportunities than full-time, specialized rescue teams, for example, then it’s imperative that those calls be directed elsewhere so firefighters don’t end up standing on shore, unable to do help, and then experience backlash.

Gillespie said student/instructor ratios should be included in the recommendations, noting that industry best practices are 12:1 for low-risk situations, 7:1 for medium risk and 5:1 for higher-risk training.

Gillespie also suggested that a standard, risk-assessment template for training be created by subject-matter experts, reviewed by the Section 21 committee, and posted on the OFMEM website for all department to access.

Under cross examination by lawyer Alex Van Kralingen, who represents the Kendall family, Gillespie reiterated the fact that the type of training undertaken on Jan. 30, 2010, in the icy, fast-moving St. Clair River, and by Herschel Rescue on Feb. 8, 2015, in the Saugeen River, should be off limits.

“I don’t choose to do training in ice and swift water,” Gillespie said.

“Is that because of the inherent danger of those conditions?” Van Kralingen asked.

“Yes.” May 17, 2017, Toronto – Repeatedly, this week and last, jurors heard at the inquest into the ice-water training deaths of Gary Kendall and Adam Brunt how dangerous fire fighting is; yet in Ontario there are no mandatory minimum standards for firefighters to get hired.

The co-ordinator of the firefighting program at Durham College, where Brunt was a student, is adamant that all firefighters should be trained and certified to NFPA 1001.

Ralph Hofmann told the inquest Tuesday that industry and government need to smarten up, shake the it’s-always-been-this-way attitude, and enforce mandatory NFPA certification.

“The challenge,” Hofmann said, “is that there has to be a willingness to change; the challenge is that [the words] standards and voluntary don’t go in the same sentence . . . To say that a standard is voluntary negates the standard.”

Pre-service firefighting students in Ontario are not required to write NFPA exams or pass practical tests before applying for jobs. Firefighters, Hofmann said, are the only emergency services students exempt from passing standardized tests after graduation. Students in other disciplines – nurses and paralegals for example – must write exams imposed by provincial standards-making bodies.

“There needs to be a willingness to do this,” Hofmann said, with support from the Ontario Association of Fire Chiefs, the Office of the Fire Marshal, unions, municipalities, and industrial firefighting operations.

“If we’re going to toss around this term NFPA, and say it’s a standard, then we need to adopt it,” he said.

Hofmann said there’s no question students take specialized courses , such as ice-water rescue, outside of the college program to give them an edge on their resumes, but the school neither condones nor promotes the programs.

Asked if legislative change might be necessary if private, third-party trainers are to be regulated, Hofmann was definitive.

“Absolutely.”

Under cross examination by Kendall family lawyer Alex Van Kralingen, Hofmann said students lack an understanding of the importance and magnitude of the NFPA testing.

“We need to harp on them the necessity to continue their studies,” he said. “They underestimate the academic rigour of these NFPA exams.”

Asked whether he sees any barriers to Durham College proving a single-skill training now offered by private operators, Hofmann cited resources, facilities and cost, but said providing the types of courses students seek to pad their resumes is do-able. (And therein lies the problem – the fact that, in some cases, taking such courses will, indeed, give a potential recruit an edge.)

“There are several challenges,” Hofmann said. “But is there an insurmountable barrier? No.”

Jurors were incredulous to learn Tuesday that municipalities choose their own hiring qualifications.

“So I can find a fire chief who maybe I know, who will hire me, and then the next day I can go out and do rescues?” asked one juror.

Not quite, but the point was well taken.

The focus of the inquest has been twofold: how to rein in unregulated third-party trainers such as Herschel Rescue; and the benefits of NFPA certification to increase firefighter safety.

Yet government wants little to do with private, third-party trainers. Terry Trotter, the manager of compliance and enforcement with the Ministry of Advanced Education and Skills Development, said Tuesday that single-skill programs such as Herschel Rescue’s ice-water course fail to meet criteria for private career colleges; those institutions must provide a minimum of 40 hours of training and lead students to potential jobs.

Nor do the private operators fit into the mandates of the ministries of consumer affairs or community safety.

* * *

The exceedingly uncomfortable benches in the coroner’s courtroom were mostly filled Tuesday by observers anxious to hear testimony by the Office of the Ontario Fire Marshal’s standards and training manager.

But the information provided by Kaplana Rajgopalan Tuesday morning is critical to the five jurors trying to understand the nuances of firefighter training in Ontario – a gargantuan task for fire-service professionals, let alone lay people.

The jurors are expected to make recommendations to prevent deaths similar to those of Point Edward firefighter Kendall, and Brunt, who was from Clarington, Ont.

Herschel Rescue was not authorized to certify firefighters to NFPA standards – although Point Edward Fire Chief Doug MacKenzie testified last week that he understood his crew had indeed been certified after ice-water rescue training in 2009.

In fact, as the jurors have heard, Herschel Rescue principle Terry Harrison had only to apply to the province for a business number and, as one lawyer said last week, could “hang out a shingle” as a specialty rescue trainer.

Some context: under the Fire Protection and Prevention Act, the OFMEM is required to provide training to firefighters in Ontario. The OFMEM is the only entity in the province that has the authority to certify students to NFPA standards.

Courses are run by the Ontario Fire College. But the college, at the moment, offers no courses in water rescue or ice-water rescue (let alone swift-water ice rescue), the programs having been put on hold until to focus on core courses, and until the 2017 edition of the standard becomes available. The college, jurors heard, offers no testing for water rescue, ice-water rescue or swift-water ice rescue training.

It was interesting to watch jurors react and respond to Rajgopalan’s detailed and well-delivered testimony, processing the fact there is are no provincial minimum qualifications for hiring (volunteer or career firefighters), that municipalities set their own requirements, that there are committees and a technical table (a government term if ever there was one) considering potential changes to training and possible adequacy standards, but it’s all up in the air until the 2017 standard for technical rescue becomes effective.

Jurors heard the difference Tuesday between Harrison’s unregulated program and that of the Fire and Emergency Services Training Institute (FESTI), a private career college that Deputy Chief David Lane said adheres to strict safety protocols and is overseen by the OFMEM.

Everyone, it seems, agrees that training in dangerous disciplines such as rope rescue and ice-water is necessary,

“Training is necessary,” Rajgopalan said, “it’s just how to provide that.”

“I think the option is to offer that training in a regulated environment, through a regional training college or other regulated providers that offer access to safe training.”

Rajgopalan said it would be possible for the OFMEM to work with private trainers if they complied with already existing standards.

“Those that are providing that could meet the requirements of the private career colleges act and could, in-turn, be a regulated provider, but, in turn, if they are not able to meet the requirements, they should not be a regulated provider.”

“Do you think certification should be mandatory?” Rajgopalan was asked.

“Yes. Certification for the adoption of professional qualification standards would certainly help to further the requirements, yes.”

Asked if she had any recommendations for the jury to consider, Rajgopalan was clear.

“A lot of the themes that have come out [during the inquest] are around safety, making sure the programs are offered in a regulated environment . . . perhaps the adoption of standards beyond voluntary, and the adoption of standards for the high-risk [training].

“Maybe,” Rajgopalan said, “as we’re looking to the 2017 edition [of the 1670 standard for technical training], one of the things we could consider is defining the locations where this training could be undertaken safely.”May 14, 2017, Toronto - The mandate of a coroner’s inquest is to determine who died, when, where, how, and by what means the death(s) occurred.

We know Point Edward volunteer firefighter Gary Kendall and Durham College firefighting student Adam Brunt drowned during ice-water rescue training in the St. Clair and Saugeen rivers, respectively.

We know, from an earlier trial after which trainer Terry Harrison, principle of Herschel Rescue, was acquitted of a single charge under the Occupational Health and Safety Act, details of the difficult conditions and the perhaps-unwise decisions to venture into challenging, swift water.

According to the Ministry of Community Safety website, an inquest is NOT (capital letters not mine) an adversarial process. “It is also neither a trial, nor a process for discovery.”

You could have fooled me.

Adversarial. Intense. Sensational. And disturbing.

Friday’s proceedings at the inquest into the deaths in 2010 and 2015 were particularly outrageous, with counsel pushing the limits of reasonable questioning.

See, Harrison has no lawyer; he represents himself, unable to afford, he has said, counsel for the two-week inquest and myriad hours of preparation.

Objectively, in my view as a former court reporter, Harrison has done well, astutely cross examining witnesses and, for the most part, has kept his cool – although some of his answers have been less than polite, which is understandable given the circumstances.

Indeed, Harrison has forced testimony from witnesses that in some cases has clarified and contradicted what lawyers blatantly misconstrued or misrepresented.

But late last week, Harrison testified. And he was grilled – by coroner’s counsel, and by lawyers for the Kendall and Brunt families. Rightly so.

But with no counsel to object to leading questions, adversarial tones, and irrelevant lines of discourse, Harrison was challenged to hold it together and, under extreme duress, answered questions to which he probably needn’t reply, the lawyers having succeeded in getting certain information on the record through their enquiries.

In a trial, of course, accused who are unable to retain counsel are provided legal aid. Not so in an inquest.

While I have strong opinions about the incidents, third-party trainers, and the lack of government regulations, it’s all a bit appalling, and, to my mind, clearly a process for discovery for likely civil suits.

Harrison has been called by at least one witness a “maverick,” a bit of a cowboy in ice-water rescue, known to encourage students to be aggressive during training.

Firefighters and a fire chief have testified that the type of training Harrison provides is critical so that rescuers know what to do in challenging circumstances. (Taking college students into similar conditions is another matter.)

Asked Friday by Alex van Kralingen, the lawyer for the Kendall family, if anyone should train in such extreme environments as the swift-water section of the St. Clair River or in the boil at the foot of the low-head damn in the Saugeen, Harrison – thinking quickly – cited the rescue of a young woman perched precariously on the block of a crane in Toronto a few weeks back.

“Nobody would think a fire department is going to have to do that kind of a rescue,” Harrison said.

“That individual on the fire department was trained to a level greater than that. If you expect the Point Edward Fire Department or the Hanover Fire Department to perform rescues in the areas that you’re asking them to perform rescues in, then yes they should train in those areas.”

That said, Harrison has no authority to grant certification; he has no insurance – nor is he required to. There is no curriculum oversight for Herschel Rescue courses, no testing.

Harrison admitted, under tough questioning, that he joined Durham College students for drinks and at a strip club the night before training. Irrelevant? Maybe. But with no counsel, the lawyer had at him.

A series of blunders: Harrison shown in a YouTube video wearing a white helmet with an Office of the Fire Marshal logo on it, well after he had ceased being an instructor at the Ontario Fire College; a student-teacher ratio of 12:1 that conflicted with Harrison’s own recommendations; no knowledge of how to acquire a defibrillator; no emergency plan; losing sight of students during training.

“Did you attempt to find somebody to help you that weekend?” asked Raymond Watt, lawyer for the Brunt family, referring to the 12:1 student-teacher ratio.

“Yes.”

“What happened?”

“No one was available.”

“So if no one was available, why didn’t you cancel the course? Can I assume you thought you would take the risk and do it yourself?”

“Yes,” Harrison said. “You could assume that. Because I didn’t think there was a risk. I was confident in the progression style of my course that it would work out very well.”

“It didn’t work out well in the end, did it?

“No, it didn’t.”

“If I suggest to you,” Watt said, “that one of the main reasons Adam drowned was because you were conducting this exercise in the wrong place, would you agree with me? Would you agree with me that there are safer areas in southern Ontario do to this exercise with these people? That there are safer areas where you wouldn’t have had the problem you had?”

“Maybe.”

“You’re actually trying to teach people how to save lives and you lost two. Correct ?

“Yes.”

“Physically, you were unable to extricate [Adam] because of the flow of the water, correct?”

“Yes.”

“When you’re doing these training exercises you are doing what you’ve been doing all your life – you push people to their limits, and as a result of that you’ve had two fatalities. Do you agree?”

“Do I push them? Yes I do.”

“In fact,” Watt said, “you push them too hard.”

“No,” Harrison said, “I don’t.”

The inquest resumes Monday.

May 12, 2017, Toronto – I was a bit confused Thursday at the inquest into the ice-water training deaths of firefighter Gary Kendall and firefighting student Adam Brunt.

The inquest started Tuesday; the focus this week is on Kendall, the 51-year-old volunteer firefighter from Point Edward, Ont., who died after becoming trapped in the St. Clair River on Jan. 30, 2010.

Firefighters and Fire Chief Doug MacKenzie have given similar testimony about the events and circumstances of that fateful day; indeed, so much detail has been provided that that the five coroner’s jurors are asking questions as insightful as the lawyers for the parties with standing.

Yesterday, however, the lawyer for the Office of the Fire Marshal and Emergency Management introduced into evidence a copy of a certificate in ice-water rescue issued to Gary Kendall in 2009 by Herschel Rescue, the private company hired on several occasions to provide training to Point Edward firefighters.

The document states that Kendall had completed a training course Ice Rescue NFPA 1670 Technician.

Therein lies the confusion – and not just mine. Indeed, Chief MacKenzie understood that his firefighters had been certified to NFPA 1670 technician. Which was not the case.

Herschel proprietor Terry Harrison had been sought by the Office of the Fire Marshal in the early 1990s to help develop an ice-water rescue program after an inquest into the death of firefighter Harry Chevalier recommended that the province do so.

Harrison was, by all accounts, a highly regarded trainer who later furthered his expertise through courses in Michigan, Ohio, Indianapolis and Pennsylvania, and was hired, along with other instructors, by the Ontario Fire College to deliver its ice-water rescue training. Neither Harrison’s LinkedIn page nor his company’s Facebook page list his credentials.

Harrison ran Herschel Rescue on the side while instructing for the fire college and working as a career firefighter in Brampton. But in 2008 the college determined that its instructors could not also run private training operations. Harrison chose to maintain his private school, and ceased teaching for the fire college.

As I understand it, the Office of the Fire Marshal is the only authority in the province that has jurisdiction to certify students to NFPA standards; IFSAC and ProBoard in the United States grant that jurisdiction to other training outlets, but Herschel Rescue is not among them.

“In Ontario, the Office of the Fire Marshal is the provincial certifying body for firefighters and other fire department personnel,” the OFM website says.

Kendall’s certificate is signed by Harrison. Photocopy-style logos from the Ohio State Fire Academy and Michigan Urban Search and Rescue appear on the certificate; it’s not clear why. Upon careful examination, there is no indication of certification to the NFPA 1670 standard, simply the words completion of a 20-hour training course Ice Rescue NFPA 1670 Technician, and the date, Feb. 6-8, 2009.

As Chief MacKenzie testified, “In 2009, we were getting certification in ice rescue, through Harrison’s company, for NFPA, and not just through Herschel, but he had a bunch of different names or stamps on it. I believe that we were certified for ice rescue technician and could move on [to the next level].”

Asked where he believed the certificate was produced, Chief MacKenzie said he didn’t know, nor did he know whether Herschel had the ability to issue certification for all those agencies, despite the fact that there was no testing, and no Ontario Fire College instructors came to evaluate the participants.

Harrison testified Thursday afternoon that there were no quizzes or exams in his 2.5-day program that involved class time, familiarization with equipment, a swim test, and in-water evolutions.

“My program was set up on the ideal that every two years there would be recertification,” Harrison said.

The fire college stopped teaching ice-water rescue in 2014, but even when the program was available, volunteer departments struggled to get their members to the courses at or near the fire college in Gravenhurst. Hence the development of private training providers for ice-water rescue and other specialized training unavailable through the province.

Ultimately, Chief MacKenzie testified, he was unaware that when the fire college offered ice-water rescue courses it did so only in still water rather than swift water; additionally, he said, the fire department would be unlikely to affect a rescue in the St. Clair River, where the training occurred and where Kendall drowned.

“We have never had a save in that river,” he said.

MacKenzie said the province should regulate private training providers, and there should be a provincial standard for ice-water rescue.

Asked why he chose to have his firefighters train in inherently dangerous circumstances, Chief MacKenzie said there’s an expectation that the fire department will respond.

“ . . . if we don’t do anything I guarantee you we are going to be crucified as a department,” he said.

Coroner Dr. William Lucas took issue with that.

“If your firefighters were at a house fire that was fully engulfed, you wouldn’t for a moment think about sending in your firefighters in if you thought there’s any chance they would die, and would you agree with me that probably public perception would support you on that?”

“I’ve been doing this for a long time,” MacKenzie said. “And there are a handful of people who would think you’re the greatest thing and another handful that would be bashing you.”

Lawyer Alex van Kralingen, who represents the Kendall family, asked MacKenzie if he was aware that when the fire college offered ice-water rescue that it did so only in still water.

“No.”

“Would the fact that the [fire college] does not combine ice-water rescue training with a swift-water environment have affected your decision to hire Mr. Harrison?” Mr. van Kralingen asked.

“Possibly.”

“Why?”

“Because if the college is doing that there’s got to be a reason.”

“Would it have helped you,” van Kralingen asked, “for the Ontario Fire College to have communicated that to you at some point?”

“Absolutely.”

May 11, 2017, Toronto – It was an astute juror, rather than one of myriad lawyers at the inquest into two firefighter training deaths, who asked the most poignant question on Wednesday: “Do you think ice-water rescue training should be required?”

The question was posed to Point Edward, Ont., volunteer Lt. Rick Burdett by one of five jurors, a man who spoke softly and chose his words carefully, almost apologetically, after hearing horrific testimony detailing the circumstances of an ice-water rescue training exercise that went awry.

Burdette explained how he came this close to drowning in the St. Clair River, this close to being crushed between an ice floe moving at remarkable speed in a ferocious current, and jagged chunks of shore ice, but was, at the last second, grabbed and hauled out of the churning water.

“It just kept breaking and breaking,” Burdett said of his efforts to grab the edge of the ice floe. “I kept doing it until I had nothing left. You’re fighting for your life just to break the ice and get on top of it.

“I was losing strength and just yelling for help,” Burdett testified. “And firefighter Ryan Carr was right there and grabbed my hand; whatever he did to get me up onto the floe . . . we just kept rolling and rolling to get to a thick enough point that it would hold us.”

Neither throw bags, ice picks, a whistle, nor an on-shore rapid intervention team would have helped, Burdette said, the circumstances such that he had to keep pawing at the thin edge of the ice flow and breaking off pieces to keep from being crushed.

“If Ryan Carr didn’t pull you out,” Burdette was asked by counsel for the family of firefighter Gary Kendall, who was trapped and hauled under by the vicious St. Clair, “do you think you would have been able to self-rescue?”

Burdett shook his head no, unable, for a moment, to speak.

And then, barely audible: “I wouldn’t have been able to.”

It’s hardly surprising, then, that the jurors – all lay people, all dutifully listening to sometimes combative, sometimes technical, and sometimes gut-wrenching testimony – wondered why firefighters risk their lives to train to rescue people in the raging St. Clair after hearing that they are rarely called to do so, and generally in more favourable conditions than the river offered on Jan. 30, 2010.

Burdett’s response to the juror’s question, Do you think ice-water rescue training should be required?

Yes.

“If you don’t have something for the departments,” Burdett said, “anybody who’s on shore is going to go out there after [a trapped person], so it would be better to have somebody who’s trained than your average Joe off the street.”

Asked subsequently whether training should occur on the St. Clair or, instead, in less dangerous still-water conditions, Burdett’s response was typical.

“We should be training in the area that we are responding to,” he said. “We don’t have ponds and pools that people are drowning in; it’s the fast water that people are getting caught in.”

Burdett lives close to the river; on Jan. 30, 2010, the St. Clair was in rare form, he said, something he hasn’t seen since.

“Ever since that’s happened,” Burdett testified, “I’ve been down to the river many times and it doesn’t flow that way all the time. It was just, I don’t know . . . Mother Nature gone bad.”

Similarly, Capt. David Dobson, who also struggled in the mighty St. Clair on Jan. 30, 2010, and who testified that conditions changed quickly, said training has to be realistic.

Sarnia firefighter Daniel Nelles gave confusing testimony earlier in the day about safety precautions during the ice-water exercise, but similarly said it’s critical for rescuers to train for the circumstances in which they work.

“The Office of the Fire Marshal has ceased [ice-water] training, and management doesn’t want to be in a position that they’re held accountable for a similar type incident,” Nelles said. “But by not training in the St. Clair River, we [would be] putting ourselves at a liability of not training in the same environment in which we may be rescuing.”

The departments ceased training in the moving part of the St. Clair after Jan. 30, 2010, doing so only in the protected harbor, “until there’s more information gathered and we can be on a firmer footing as to what our abilities are as a department,” Nelles explained.

The inquest is examining Kendall’s death and that of firefighting student Adam Brunt on Feb. 8, 2015; both died during training provided by Brampton-based Herschel Rescue, an unregulated third-party training operation run by Terry Harrison.

Witnesses testified Wednesday that there was accountability, a rescue truck on shore with a defibrillator, a platoon system in place, strict instructions given by Point Edward Chief Doug MacKenzie for firefighters to be aware of their physical limits and ensure each other’s safety, and a lesson on hand signals.

MacKenzie testifies Thursday, followed by Harrison.May 10, 2017, Toronto - The inquest that started Tuesday into the drowning deaths of firefighter Gary Kendall and firefighting student Adam Brunt is scheduled to run just a couple of weeks.

As is the norm with coroner’s inquests, there is no public list of witnesses, parties with standing, or lawyers, and no daily transcripts to help interested observers ensure accuracy given the sometimes inaudible testimony from nervous or emotional witnesses.

As a fire chief from out of province with experience in inquests suggested in an email exchange today, “This looks like a government issue and they don’t want any more truth than needed.”

There may be some truth to that: third-party trainers in Ontario are unregulated and, seemingly, no provincial ministry wants to touch them with a ten-foot pike pole.

Hence the expected short duration of the proceedings.

Some third-party operations, of course, claim to train to NFPA standards and have impeccable records.

But for the myriad trainers ostensibly selling prospective firefighters a greater chance to get hired, or helping volunteers develop new skills, there is no government oversight: not the Ministry of Training, Colleges and Universities; not the Ministry of Advanced Education and Skills Development; not the Ministry of Government and Consumer Services; not the Ministry of Community Safety (which includes the Office of the Fire Marshal and Emergency Management).

The purpose of the inquest is to make recommendations to prevent similar deaths: Kendall, 51, a volunteer firefighter in Point Edward, and Brunt, 30, a Durham College firefighting student from Clarington, died during separate water-rescue training in 2010 and 2015, both during evolutions being run by third-party trainer Herschel Rescue.

Unsurprisingly, a 1990 inquest into drowning deaths of a firefighter in Port Colborne, Ont., recommended "a standard code of rescue practices for shore-based water rescue units,” and urged the Office of the Fire Marshal to develop and offer a course in water and ice rescue. That was seventeen years ago. Jeffrey Attwell, the acting academic manager for the Ontario Fire College, Tuesday failed to explain clearly why the Ontario Fire College offers no ice-water rescue courses.

A course had been developed and delivered after the 1990 inquest but was divided into segments and ceased in 2014; the timeline for a new course that will ensure participants remain out of the water is not clear.

But before Attwell completing his evidence, coroner Dr. William Lucas asked him to provide an example of ice-water situations so dangerous that an incident commander would refrain from sending firefighter to attempt a rescue.

“In certain cases, at a low-head damn,” Attwell said.

And a structure fire, Attwell added, with fire venting through all openings.

“What I don’t understand,” said Lucas, “is why would you send firefighters into swift water if all may be lost.” Exactly.

After Attwell gave his chief evidence, Lucas returned to a point Attwell had made earlier, about the need to train firefighters to understand they can’t rescue everyone from every situation.

“In many cases,” Attwell said, “firefighters need to be taught that they didn’t create the emergency and they can’t always solve the problem.”

As is the norm in Ontario, multiple deaths and multiple inquests are necessary before anyone does anything – there were several inquests into fire fatalities in Ontario seniors homes before sprinklers became mandatory, and that was only after Herculean lobbying efforts by the Ontario fire service.

Coroner’s council Michael Blain told jurors Tuesday a strap on Brunt's suit got snagged on something under the water — it was earlier reported to have been rebar – as he tried to float through a gap in the ice in the Saugeen River.

Kendall was among a group of firefighters instructed to swim to an ice floe and climb onto it, but the floe began to move and Kendall was trapped underneath for several minutes.

Terry Harrison, the principle of Herschel Rescue, represents himself at the inquest. He was acquitted in 2012 on one charge under the Occupational Health and Safety Act in Kendall's death. Three other charges were dismissed.

Herschel Rescue, like most third-party trainers, is an unregulated training operator. No organization that has an interest in the fire service – the Ontario Association of Fire Chiefs, the Fire Fighters Association of Ontario, the Ontario Professional Fire Fighters Association, the Ontario Association of Fire Training Officers – has a mandate or authority to regulate third-party providers.

It seems odd that the ministry that regulates student firefighter training in community colleges and private career institutes across the province, yet lacks regulatory authority over third-party providers.

To be fair, no one likely contemplated the need for regulation until Kendall’s death, nor the fact that the same training provider would be involved in two similar fatalities.

Still, the solution seems simple. As Dr. Lucas intimated Tuesday, why put rescuers unnecessarily at risk in the first place?